Proximal Mainstem Bronchus Research Articles

Complete Lung Atelectasis Following Caesarean Section in a Case of Imminent Eclampsia- A Case Report

In the early postpartum period, acute life-threatening problems can occur and cause maternal morbidity and mortality. In the present case report, a 19-year-old primipara had undergone caesarean delivery following which she developed breathlessness, tachycardia and fall in oxygen saturation after 14 hours of surgery. Her Chest X-Ray (CXR) report confirmed a complete collapse of the left lung. Contrast-enhanced Computed Tomography (CECT) of the thorax showed a complete collapse of the left lung due to obstruction at the level of the proximal main stem bronchus. Medical management with mucolytics was administered. The patient showed improvement clinically and a repeat CXR after 24 hours showed normal lung findings with complete resolution of collapse and medical management was continued. The patient recovered progressively and follow-up of the patient was uneventful. This is a rare case of development of respiratory distress and atelectasis, hence proper diagnosis is essential.

A RARE CASE OF HUMAN PAPILLOMAVIRUS-ASSOCIATED TRACHEAL SMALL CELL CARCINOMA

A RARE CASE OF HUMAN PAPILLOMAVIRUS-ASSOCIATED TRACHEAL SMALL CELL CARCINOMA

Dimensional compatibility of rigid ventilating bronchoscopes with pediatric airway anatomy using different recommendations for age-related sizing-A bench study.

Appropriate size selection of pediatric rigid bronchoscopes is fundamental to avoidance of airway trauma and to a high success rate with the first intubation attempt. The aim of the present study was to compare the outer diameters of pediatric rigid bronchoscopes with the anatomical data on the pediatric airway. Outer diameters (OD) of pediatric rigid ventilating bronchoscopes as given by the manufacturer were compared with published computed tomography internal diameters (ID) of the cricoid outlet, the trachea as well as the left and right proximal mainstem bronchus, using six published recommendations for age-related size selection. The ratios between a specific OD and ID were calculated and given as percentage values (%) for lower and upper age ranges. Nominal sized 2.5, 3, 3.5, 3.7, 4, 4.5, 5, and 6 rigid bronchoscopes were included. In five recommendations, the rigid bronchoscopes' OD was larger than the internal cricoid diameter in the upper age range, whereas in one recommendation the ratio (OD rigid bronchoscope to ID of cricoid) ranged between 77% and 90% for the upper age and between 95% and 109% for the lower age range. In only one of the six recommendations was the rigid bronchoscope OD larger than the tracheal ID. Ratios for the left and right proximal mainstem bronchus ranged from 70% to 146% for the upper and from 78% to 156% for the lower age range, with the highest ratios for the left proximal mainstem bronchus. Based on this in vitro study, most of the recommendations analyzed result in a balanced fit of rigid bronchoscopes within the cricoid. Since the left mainstem bronchus is considerably smaller than the cricoid, any insertion on this level will require careful endoscopic guidance to avoid damage to the left mainstem bronchus.

S1973 Achalasia With Diffuse Esophageal Dilation Causing Tracheal Compression and Severe Asthma

INTRODUCTION: Achalasia is a rare esophageal disorder that is caused by the lack of relaxation of the lower esophageal sphincter, causing loss of peristalsis and a dilated esophagus. Patients present with various upper gastrointestinal complaints. Here, we present the case of a 16-year-old female with history of uncontrolled asthma, including intubation at age 14 for status asthmaticus, who was found to have a massively dilated esophagus causing compression of the trachea. Peroral endoscopic myotomy (POEM) was performed and she experienced complete regression of her asthma symptoms. CASE DESCRIPTION/METHODS: 16-year-old female with history of uncontrolled asthma presents to pulmonology clinic. Pulmonary function testing (PFT) demonstrates severe obstruction (FEV1 33%, FEV1/FVC 45%) with little improvement following a 5-day course of oral steroids. She endorses mild, nonproductive cough. She appears well, speaking full sentences and ambulating without difficulty. She has diminished breath sounds bilaterally. Labs reveal only mild normocytic anemia. She is started on intravenous steroids and inhaler therapy. CT chest without contrast shows diffusely distended esophagus filled with liquid and food debris, exerting mass effect on the trachea and proximal mainstem bronchi, as well as diffuse groundglass opacities and scattered pulmonary nodules. Upon further assessment, the patient endorses occasional dysphagia with solid foods. She has infrequent vomiting episodes but denies odynophagia or weight loss. Eckardt score is 5. EGD reveals dilation in the entire esophagus; EndoFLIP reveals decreased distensibility and absent contractility consistent with type I achalasia. The following day, POEM procedure is performed. Post-procedure Eckardt score is 0. She is discharged home on lansoprazole 30 mg twice daily for 2 months. Over the next 6 months, she experiences complete remission of her asthma symptoms and inhaler therapy is discontinued. She also has complete resolution of dysphagia and gains 50 pounds. DISCUSSION: In our case, the patient had worsening PFT despite adequate treatment for asthma. Chest CT found a dilated esophagus, which may have been present 2 years prior when she was intubated for status asthmaticus. Her respiratory symptoms regressed completely after POEM for achalasia. This case demonstrates the importance of diagnostic review, especially in cases of primary treatment failure. Maintaining a broad differential can help clinicians think critically and correct potential reversible causes.Figure 1.: Chest CT shows diffusely dilated esophagus, likely secondary to achalasia.Figure 2.: Dilated esophagus causing compression of proximal mainstem bronchus.Figure 3.: Liquid and food debris in dilated esophagus near the LES.

Dimensional compatibility of balloon-tipped bronchial blockers with the pediatric airway anatomy using different recommendations for age-related size selection.

Age-related recommendations for size selection of bronchial blocker devices are based on a few dated anatomical autopsy and radiological studies determining lower airway dimensions in children. These recommendations are based on anterior-posterior internal bronchial diameters, which are smaller than the more relevant lateral internal bronchial diameters. Outer diameters of bronchial blocker balloons inflated with the maximum recommended volume of air were compared to age-related lateral internal bronchial diameters of left and right proximal mainstem bronchi using five different recommendations for age-related size selection of bronchial blocker equipment in children published in the literature. The ratio of outer bronchial blocker diameters inflated with the maximal recommended volume of air to the median lateral internal diameters of the proximal mainstem bronchus ranged from 71.4% to 181.8% for the left side and from 61.7% to 162.6% for the right side. There were many settings where the blocker diameters did not reach the median lateral internal diameters of the proximal mainstem bronchus. This was more often observed for the right than for the left side (37 vs 22 settings). This analysis demonstrates that irrespective of the recommendation for size selection used, neither the two balloon-tipped vascular catheters included nor the Arndt endobronchial blockers are ideal for lung isolation in children are compared with the age-related relevant dimensions of pediatric airway anatomy. A redesign of bronchial blocker equipment with age-related anatomically based high-volume, low-pressure blocker balloons made from ultrathin membranes and with smaller catheters would be desirable.

Carinal resection and reconstruction following inflammatory myofibroblastic tumor resection: A case report

Abstract Inflammatory myofibroblastic tumors (IMT) are rare tumors of the respiratory tract that most commonly occur in the lung and are rarely seen in the trachea. They present most often in young patients. We report on a case of an IMT of the carina in a seven year old girl, requiring carinal resection and reconstruction with a novel technique in pediatric airway surgery. Attempts at endoscopic excision of the carinal IMT were unsuccessful. An open approach for resection of the involved carina, distal trachea, and proximal mainstem bronchi was performed via sternotomy and cardiopulmonary bypass. The resulting triangular defect in the trachea and bronchi was reconstructed with anastomosis of the proximal trachea and left mainstem bronchus using a rotational flap of the right lateral mainstem bronchial wall. The remaining right mainstem bronchus was anastomosed, end to side, to the intact trachea proximal to the primary anastomosis. Bronchoscopy and MRI 22 months post resection and reconstruction revealed a healthy neo-carina and patent distal airway with no evidence of recurrent IMT. Pediatric patients with carinal inflammatory myofibroblastic tumors can be successfully managed with open resection and reconstruction of the airway.

Management of Tracheomediastinal Fistula Using Self-Expanding Metallic Stents

Tracheomediastinal fistula is a rare condition usually associated with a fatal outcome. We report the case of a 65-year-old man with a subcarinal mass causing total destruction of the carina and proximal mainstem bronchi. The mass was diagnosed as a large cell lymphoma, and the decision was made to undertake chemotherapy only after stabilization of the endobronchial tree. The endobronchial defects were successfully palliated with placement of three different types of self-expanding metallic stents using a flexible bronchoscope under conscious sedation. The unique properties of each stent were used for optimum clinical benefit, avoiding any morbidity.

Initial Experience With a Rotating Airway Microdebrider

Our prior experience with microdebrider bronchoscopy treating central airway obstruction demonstrated that although the blades were extremely effective, they were not long enough to reach beyond the proximal mainstem bronchi in patients. As a result, the microdebrider could not be used in patients with disease beyond the mainstem bronchi. In this report, we describe our experience with advancement of this technology: a microdebrider with a longer, rotating blade. We employed a 45 cm in length, angle tip, and serrated rotating microdebrider blade in 20 patients from 2 academic medical centers with central airway obstruction requiring rigid bronchoscopy. We retrospectively reviewed the records of each patient over a mean period of 7.7 months of clinical follow-up to describe our experience with the new system. Dissection times ranged from 2 to 40 minutes (mean 12 min). Mild bleeding occurred in all cases and was controlled with tamponade with the rigid bronchoscope in 13 patients and with tamponade plus cautery in 7 patients. Complete patency of the airway was obtained in all patients. Eight patients required placement of a silicone airway stent at the end of the procedure because of associated airway malacia. There were no perioperative complications. The longer blade, 45 cm compared with 37 cm, allowed us to easily reach disease in the trachea, mainstem bronchi, and tributaries. Further, the ability to rotate the blade aperture in a 360-degree fashion allowed us to dissect with more precision. Additional experience with this system and microdebrider bronchoscopy in general will allow us to determine its role in routine practice.

Resection for bronchogenic carcinoma involving the carina: Long-term results and effect of nodal status on outcome

Objective: Bronchogenic carcinoma in close proximity to or involving the carina remains a challenging problem for thoracic surgeons. The operative procedures to allow complete resection are technically demanding and can be associated with significant morbidity and mortality. Little is known about long-term survival data to guide therapy in these patients. Methods: We conducted a single-institution retrospective review. Results: We have performed 60 carinal resections for bronchogenic carcinoma: 18 isolated carinal resections for tumor confined to the carinal or proximal main stem bronchus; 35 carinal pneumonectomies; 5 carinal plus lobar resections, and 2 carinal resections for stump recurrence after prior pneumonectomy. Thirteen patients (22%) had a history of lung or airway surgery. The overall operative mortality was 15%, improved from the first half of the series (20%) to the second half (10%), and varied according to the type of resection performed. Adult respiratory distress syndrome was responsible for 5 early deaths, and all late deaths were related to anastomotic complications. In 34 patients, all lymph nodes were negative for metastatic disease; 15 patients had positive N1 nodes, and 11 patients had positive N2/N3 nodes. Complete follow-up was accomplished in 90%, with a mean follow-up of 59 months. The overall 5-year survival including operative mortality was 42%, with 19 absolute 5-year survivors. Survival was highest after isolated carinal resection (51%). Lymph node involvement had a strong influence on survival: patients without nodal involvement had a 5-year survival of 51%, compared with 32% for patients with N1 disease and 12% for those with N2/N3 disease. Conclusions: This constitutes one of the largest single-institution reports on carinal resection for bronchogenic carcinoma involving the carina. Morbidity and mortality rates are acceptable. The overall survival including operative mortality is 42%. Positive N2/N3 lymph nodes may be a contraindication to surgery because of poor prognosis. (J Thorac Cardiovasc Surg 2001;121:465-71)

Treatment of bronchopleural fistula after pneumonectomy

Breakdown of the closure of the main-stem bronchus after pneumonectomy is a dreaded complication, and empyema and bronchopleural fistula frequently develop in patients who survive. Management of these fistulas remains a formidable therapeutic challenge, which has been approached with a variety of surgical techniques. We report our experience with anterior transpericardial closure, emphasizing the ability to expose either main-stem bronchus by this approach. The case histories of three patients who had bronchopleural fistula after pneumonectomy are presented. The first patient had left pneumonectomy for complicated tuberculosis; the second had right pneumonectomy for neoplasm; and the third had right pneumonectomy for trauma. All fistulas were treated surgically via a median sternotomy and transpericardial approach to the distal trachea. The posterior pericardium was divided between the superior vena cava and aorta. In-continuity staple closure (with two lines of staples) of the proximal main-stem bronchus was employed in all cases. Two patients remain clinically well 21 and 17 months after the operation. The third patients did well initially but developed a recurrent bronchopleural fistula 2 1/2 months after the operation and has required repeat closure with pedicled muscle flaps. In postpneumonectomy bronchopleural fistula, the anterior, transpericardial approach to bronchial closure has several advantages: the relatively well-tolerated median sternotomy, the avoidance of dealing directly with areas of postoperative scarring and the devascularized bronchial stump, the avoidance of areas of chronic sepsis, and the avoidance of thoracoplastic surgical deformity of the chest wall, with possible associated compromise in pulmonary function. Our experience also indicates that either main-stem bronchus is accessible through an approach between the superior vena cava and aorta, without division of either pulmonary artery.

Accuracy of chest computerized tomography in detecting malignant hilar and mediastinal involvement by squamous cell carcinoma of the lung.

The accuracy of chest computerized tomography (CT) in detecting malignant hilar and mediastinal involvement by squamous cell carcinoma of the lung is examined. The preoperative chest CT scans of 74 patients with pathologically proven squamous cell lung carcinoma were prospectively and retrospectively reviewed. Criteria for the diagnosis of malignant hilar involvement were nonvascular mass enlarging the hilum; local alteration of hilar contour; adenopathy greater than 1 cm; thickened posterior wall of the bronchus intermedius and distal upper lobe bronchi; and bronchial displacement, compression, and obstruction. Criteria for the diagnosis of malignant mediastinal involvement were confluence of tumor with the mediastinum, altered contour of the azygoesophageal recess, thickened posterior wall of the proximal main stem bronchi, and mediastinal adenopathy greater than 1 cm. Calcified hilar and mediastinal nodes were considered benign. Our results, corrected for reader error, were 92% sensitive, 92% specific, and 96% accurate in the hilum and 95% sensitive, 77% specific, and 82% accurate in the mediastinum. These data support a significant role for chest CT in the preoperative staging of non small cell lung carcinoma.